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    Roster of Non-Licensed Personnel Who Have Successfully Completed The Texas Approved Training Program in Medication Administration

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    Robin Ainsworth Lowrie
    This document is a roster form for reporting individuals who have completed medication aide training programs in Texas. It requests information like names, addresses, social security numbers, and permit numbers of up to 12 trainees. The form must be signed by registered nurse and pharmacist instructors, and the dean or director of the training institution. It is submitted to the Texas Health and Human Services Commission to document completion of medication aide certification programs.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Roster of Non-Licensed Personnel Who Have Successfully Completed The Texas Approved Training Program in Medication Administration

    Uploaded by

    Robin Ainsworth Lowrie
    312 views2 pages
    This document is a roster form for reporting individuals who have completed medication aide training programs in Texas. It requests information like names, addresses, social security numbers, and permit numbers of up to 12 trainees. The form must be signed by registered nurse and pharmacist instructors, and the dean or director of the training institution. It is submitted to the Texas Health and Human Services Commission to document completion of medication aide certification programs.

    Original Description:

    texas med aide state roster. blank

    Original Title

    5504-MA (1)

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    This document is a roster form for reporting individuals who have completed medication aide training programs in Texas. It requests information like names, addresses, social security numbers, and permit numbers of up to 12 trainees. The form must be signed by registered nurse and pharmacist instructors, and the dean or director of the training institution. It is submitted to the Texas Health and Human Services Commission to document completion of medication aide certification programs.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    312 views2 pages

    Roster of Non-Licensed Personnel Who Have Successfully Completed The Texas Approved Training Program in Medication Administration

    Uploaded by

    Robin Ainsworth Lowrie
    This document is a roster form for reporting individuals who have completed medication aide training programs in Texas. It requests information like names, addresses, social security numbers, and permit numbers of up to 12 trainees. The form must be signed by registered nurse and pharmacist instructors, and the dean or director of the training institution. It is submitted to the Texas Health and Human Services Commission to document completion of medication aide certification programs.

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    © All Rights Reserved
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    Form 5504-MA

    May 2021-E

    Medication Aide Program


    Roster of Non-Licensed Personnel Who Have Successfully Completed
    the Texas Approved Training Program in Medication Administration
    Please type and/or generate by computer. Use separate roster reports for the basic course and the continuing education
    course.
    To: Texas Health and Human Services Commission From:
    Medication Aide Program
    Name of Approved Training Institution
    Mail Code: E-416
    P.O. Box 149030 TX
    Austin, Texas 78714-9030 City State ZIP Code

    Basic 140 Hours Training Course Continuing Education Training Course Date Training Completed:

    1. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    2. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    3. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    4. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    5. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    6. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email
    Page 2 / 05-2021-E

    7. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    8. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    9. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    10. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    11. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    12. Last Name First Name MI Social Security No. Permit No.

    Address Field City ZIP Code

    Email

    Signature — RN Instructor Program Hours Taught (RN)

    Signature — RPH Instructor Program Hours Taught (RPH)

    Signature — Training Institution Dean/Director Date (mm/dd/yyyy)

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